CLINICAL GUIDELINES

Spine Surgery Guidelines Version 1.0.2018 Effective October 22, 2018

Clinical guidelines for medical necessity review of comprehensive musculosekletal services. © 2018 eviCore healthcare. All rights reserved. Regence Comprehensive Musculoskeletal Management Guidelines: Spine Surgery V1.0.2018

Spine Surgery Guidelines CMM-600: Preface to Spine Surgery Guidelines 3 CMM-601: Anterior Cervical Discectomy and Fusion 6 CMM-602: Cervical Total Disc Arthroplasty 7 CMM-603: Electrical and Low Frequency Ultrasound Bone Growth Stimulation (Spine) 8 CMM-604: Posterior Cervical Decompression (Laminectomy/Hemilaminectomy/ Laminoplasty) with or without Fusion 9 CMM-605: Cervical Microdiscectomy 20 CMM-606: Lumbar Microdiscectomy (Laminotomy, Laminectomy, or Hemilaminectomy) 26 CMM-607: Primary Vertebral Augmentation (Percutaneous Vertebroplasty/Kyphoplasty) and Sacroplasty 33 CMM-608: Lumbar Decompression 34 CMM-609: Lumbar Fusion (Arthrodesis) 41 CMM-610: Lumbar Total Disc Arthroplasty 42 CMM-611: Sacroiliac Joint Fusion or Stabilization 43 CMM-612: Grafts 51

Spine Surgery

© 2018 eviCore healthcare. All rights reserved. Page 2 of 57 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery CMM CMM CMM - - 600.2: Urgent/Emergent Requests Urgent/Emergent 600.2: Requirements Authorization Prior 600.1: - 600: Preface to Spine Surgery Guidelines B Place B oulevard, S luffton, C 29 910 •( - 800) 918

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Spine Surgery Regence Comprehensive Musculoskeletal Management Guidelines: Spine Surgery V1.0.2018

CMM-600.1: Prior Authorization Requirements  Prior-authorization requests should be submitted at least two weeks prior to the anticipated date of an elective spinal surgery.  Minimum documentation requirements needed to complete a prior authorization request for spinal surgery include ALL of the following:  CPT codes, disc level(s) for planned surgery and ICD-10 codes  Detailed documentation of the type, duration, and frequency of provider-directed non-surgical treatment (e.g., interventional pain management, medication management, physical therapy, chiropractic care, provider-directed active exercise program, etc.) and the response to each treatment  Detailed documentation explaining why a sufficient trial of non-surgical treatment was contraindicated if applicable  Review of clinically meaningful improvement will be assessed for each treatment. This is a global assessment showing at least 50% improvement.  Written reports/interpretations of the most recent advanced diagnostic imaging studies (e.g., CT, MRI, Myelography) by an independent radiologist whose report shall supersede any discrepancies (when present) in interpretation  Acceptable imaging modalities for purposes of the Spine Surgery guidelines are: CT, MRI, and Myelography.  Discography results will not be used as a determining factor of medical necessity for any requested procedure. Discography use is not endorsed.  For spinal fusion surgery requests: flexion-extension radiographs based upon indications for instability and/or other plain radiographs that document failure of instrumentation, fusion, etc.  Documentation of nicotine-free status as evidenced by EITHER of the following, unless this is an urgent/emergent request, for decompression only without fusion, disc arthroplasty, or when myelopathy is present:  Patient is a nonsmoker  Patient has refrained from smoking for at least 6 weeks prior to planned surgery as evidenced by cotinine lab results of ≤ 10 ng/mL  Note: In order to complete the prior authorization process for spinal fusion surgery, allow for sufficient time for submission of lab results performed after the 6-week cessation period.

Spine Surgery

© 2018 eviCore healthcare. All rights reserved. Page 4 of 57 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare   CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery  management and is as follows: An urgent/emergent request is based on the 2018 NCQA standards for utilization imaging studies are required. directed non- indications/conditions warrants definitive surgical treatment in lieu medical condition that requires urgent/emergent treatment. The presence of such All patients being evaluated for spine surgery should be screened for indications of a

600.2: Urgent/Emergent Requests Urgent/Emergent -600.2:   making routine or non- A request for medical care or services when application of thetime frame for

consequences without the care or treatment that is the subject of the request. behavioral condition, would subject the member to adverse health In the opinion of a practitioner with knowledge of the member’s medical or due to the member’s psychological state, or Could seriously jeopardize the life, health, or safety of the member or others, B Place surgical manag B oulevard, S luffton, life threatening care determinations: ement C 29

and/or proofsmoking of 910 •( - 800) 918

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare See See Arthroplasty Disc Total Cervial For Requirements: Authorization Prior Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery guidelinesspecific for services. Asuris website Care Guidelines (MCG) as the basis for service coverage determinations. MCG’s Visit CMM Milliman Care Guidelines (S330) for Cervical Fusion (Posterior) Milliman Care Guidelines (S320) for Cervical Fusion (Anteri , BridgeSpan, Regence and they will happy be to provide you with acopy of the @ https://www.mcg.com/@ for information on p - B Place : : 601 B oulevard, Anterior Cervical Cervical Anterior S luffton,

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Spine Surgery Regence Policy DME83.11. Fo 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare Requirements: Authorization Prior Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery r Electrica Ultrasound CMM l an B Place d Low F - 603: Electrical Electrical 603: B oulevard, requency Bone Growth Stimulation (Spine S luffton, U ltraso C 29 910 •( und Bone G

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery CMM CMM CMM CMM Level Same at the Fusion Cervical Posterior without CMM CMM Fusion Posterior out or with with (Laminectomy/Hemilaminectomy/Laminoplasty) CMM CMM CMM ------604.8: References 604.7: Procedure (CPT 604.6: Non 604.5: FailedArthroplasty Cervical Disc Implant 604.4: Repeat Posterior Cervical Deco Decompression Fusion without Cervical Posterior 604.3: 604.2: Initial Primary Cervical Posterior Decompression 604.1:GuidelinesGeneral Laminoplasty) - B Place 604: (Laminectomy/Hemilaminectomy/ B oulevard,

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Posterior Cervical Decompression Decompression Cervical Posterior Indications S luffton,

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare     CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery             fusion include Urgent/emergent conditions for posterior cervical decompression with or without smoking cessation treatment in lieu The presence of urgent/emergent Requirements For prior authorization requirements, see decompression with or without fusion is always made on a case- The determination of medical necessity for the performance of posterior cervical

-604.  incapacitated Docu Vascular malformations (e.g., AVM) bladder incontinence/retention due to a neurocompressive pathology Severe or rapidly progressive symptoms of motor loss, bowel incontinence or compression Primary or metastatic Ossification of the posterior longitudinal ligament at three (3) or more levels   spinal Occipitocervical and/or Atlantoaxial (C1- Infection(e.g., discitis, epidural abscess,osteomyelitis) Epidural hematoma examinations Documentation of Congenital cervical stenosis (AP canal diameter ≤ Central cord syndrome compression Acute/unstable traumatic spinal fractures or dislocations with or without neural

Os odontoideum Congenital abnormality of occipitocervical/C1 - Rheumatoid arthritis mentation of severe debilitating pain and/or dysfunction to the point of being : General Guidelines General 1: B Place cord compression due to ANY .

B oulevard, of provider or instability or .

of theof following: Confirmatory imaging stu imaging Confirmatory

progressive neurological deficit on two separate physical

neoplastic disease S luffton,

- directed non-

C 29 indications/conditions warrants definitive surgical ANY

910 •(

of the following:of surgical management and/or proof of - CMM - 800) 918 C2) instability (non-

causing pathologic fracture, cord dies are required. 600.1: Prior Authorization Prior 600.1: 8924 C2 vertebrae

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare     ALL laminoplasty) withwithout or posterior fusion is considered medically necessary Initial primary posterior Fusion Posterior (Laminectomy/Hemilaminectomy/Laminoplasty) CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery  Performed for abuse) depressive disorder, A No previous surgeries onthe disc(s) involved flexion/extensio views lateral n Recent (within 6 months) radiographs of the cervical spine including

bsence of theof following are met: -604.2   Radiculopathy   

symptoms symptoms by herniated disc(s) and/ Recent (within 6 months) MRI/CT    following Less than clinically meaningful improvement   requestis decompression for only Documentationof nicotine -      Subjective symptoms including  Objective physical examination findings including  

B Place chiropractic provider, osteopathic or allopathic physician 6for weeks E Provider P without concordant objective physical examination findings Unremitting radicular pain to shoulder girdle and/or upper extremity Patient is a nonsmoker Nerve root tension sign ( Shoulder Abduction Relief Sign Reflex changes Motor deficit (e.g., biceps, triceps weakness) Dermatomal sensory deficit surgery as evidenced by cotinine lab results of ≤ Patient has refrained from smoking for at least 6weeks prior to planned disability without concordant U as (NRS) Scale Rating (VAS)/Numeric Significant level of pain on a daily basis defined on aVisual Analog Scale :

pidural steroid injection(s) rescription strength analgesics, steroids, and/or NSAIDs for 6 weeks nremitting radi unm Initial Primary Posterior Cervical Decompression Decompression Cervical Posterior Primary Initial A NY unless contraindicated: anaged B oulevard, and when -

directedexercise program

of theof following conditions: cervical decompression (laminectomy/hemilaminectomy/

chronic pain syndrome, secondary gain, drug and alcohol physical ALL significant behavioral health disorders (e.g.,

S luffton, cular

of the following are met: objective physical examination findings resulting in

havebeen performed examination

or osteophytes that is concordant pain to shoulder girdle and/or upper extremity with

C 29 free status with EITHER e.g.,Spurling 910 •( /selective nerve root block

BOTH

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ANY with or without without or with

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery        MyelopathywhenALLofthefollowingaremet:

     fusion with BOTH Other symptomatic instability or spinal cord/root compression requiring posterior Primary or metastatic tumor with associated cord compression and/or instability Multi spondyloepiphysealdysplasia, pseudoachondroplasia, etc.) cervical spinal instability (e.g., Down syndrome, mucopolysaccharidoses, or clinical conditions with an increased incidence of congenital and/or acquired Subluxation and/or spinal cord compression in patients with rheumatoid arthritis A concurrent stabilization procedure with alaminectomy, especially at C2 procedure at the cervicothor A concurrent stabilization procedure with corpectomy, laminectomy, or other

  Objective   Subjec         following: patient’s sympt Recent (within 6 months) MRI/CT   pathologic anatomy Recent (within 6 months) imaging study demonstrating corresponding conservative treatment Patient unresponsive to areasonable and medically appropriate course of   the following:

- level spondylotic myelopathy without kyphosis B Place Finemotor dys Upper/lower extremity weakness, numbness, or pain Frequent falls pathology New Increased Inverted brachial radial reflex Tandem walking test Pathologic Babinski sign Hoffmann sign Hyperreflexia Ataxic Grip and release Myelopathic hand Clonus MRI/CT MRI/CT tive - onset bowel or bladder dysfunctionduea neurocompressive to

B oulevard, physical examination findings including at least gait

symptoms

identifies stenosis with or without myelomalacia demonstrates spinal cord compression

muscle muscle of the following: oms and oms

function (buttoning S luffton,

test tone or spasticity including

(e

physical examination findings acic junction (i.e., C7 and T1) .g., rest, medication, cervical collar) C 29 910 •(

ANY

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare     same level is considered medically necessary Repeat posterior cervical decompression with or without posterior cervical fusionat the Posterior Cervical Level Same at the Fusion CMM   when Posterior cervical fusion without decompression CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery malposition or failure OR radiographic plain film or CT evidence of implant/instrumentation or structural bone graft   following: flexion/extension l Recent (within 6 months) radiographs of the cervical spine including procedure at same level Initial relief of symptoms following previous posterior cervical decompression fusion surgery Greater than 12 weeks since last recurrentdisc herniation) evidence of neural structure compression (e.g., either retained disc material or a Recent (within 3 months) or without with MRI   Documentationof nicotine -     Performed for abuse) depressive disorder, A bsence of

ALL -604.4: -604.3 flexion/extension lateral radiographs Subluxation or translation of more than 3.5 mm on static lateral views or dynamic at least 6weeks prior to planned surgery Cotinine level lab results showing that the patient refrainedh as from smoking for Patient is a nonsmoker connective tissue disorders ins Cervical Klippel    by Symptomatic cervical spondylosiswith instability as evidenced radiographically Symptomatic pseudoarthrosisa prior from

ONE or MORE or ONE processes onflexion/extensionlateral More than 4 mm of motion (subluxation) between the tips of the spinous segments Sagittal plane angulation of more than 11 degrees between adjacent spinal dynamic flexion/extension lateral radiographs Subluxation or translation of more than 3.5 mm on static or views lateral

of theof following criteria are met: B Place - Fusion Cervical : Posterior Feil syndrome

unmanaged Repeat Posterior Cervical Decompression with or without or without with Decompression Cervical Posterior Repeat ONE or MORE or MORE ONE tability in patients with Down s B oulevard,

ateral views ateral

chronic pain syndrome, secondary gain, drug and alcohol

when of the following: significant behavioral health disorders (e.g.,

S luffton, free status with A LL

of theof following instability as evidenced by MORE or ONE

of theof following criteria are met: C 29 posterior cervical decompression withwithout or 910 •(

EITHER EITHER - 800) 918

when Decompression without is considered medic radiographic views yndrome, skeletal dysplasia, or : contrast/CT myelogramconfirms anterior or posterior fusion procedure there is recent (within 3 months) 8924

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Spine Surgery  400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare  Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery  Performed for abuse) depressive disorder, A    bsence of

 Radiculopathy    processes on flexion/extension lateral radiographic views More than 4 mm of motion (subluxation) between the tips of the spinous segments Sagittal plane angulation of more than 11 degrees between adjacen spinal t  Myelopathy when 

 following Less than clinically meaningful improvement       Subjective symptoms including symptoms symptoms by herniated disc(s) and/ Recent (within 6 months) MRI/CT   Objective physical examination findings including    requestis decompression for only Documentationof nicotine -      Subjective

B Place P without concordant objective physical examination findings Unremitting radicular pain to shoulder girdle a chiropractic provider, osteopathic or allopathic physician 6for weeks Nerve root tension sign ( Shoulder Abduction Relief Sign Reflex changes Motor deficit (e.g., biceps, triceps weakness) Dermatomal sensory deficit E P disability without concordant U as (NRS) Scale Rating (VAS)/Numeric Significant level of pain on a daily basis defined on aVisual Analog Scale Patient surgery as evidenced by cotinine lab results of ≤ Patient has refrained from smoking for at least 6weeks prior to planned Fine motor dysfunction (buttoning Upper/lower extremity weakness, numbness, or pain Frequent falls pathology New

rescription strength analgesics, steroids, and/or NSAIDs for 6 weeks pidural steroid injection(s) rovider nremitting radi unmanaged

EITHER - onset bowel or bladder dysfunctionduea neurocompressive to unless contraindicated: B oulevard,

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of the following conditions:

ALL significant behavioral health disorders (e.g.,

S luffton, cular of theof following

including

of the following are met: objective physical examination findings resulting in examination

or osteophytes that is concordant pain to shoulder girdle and/or upper extremity with

C 29 free status with EITHER e.g.,Spurling 910 •( /selective nerve root block

BOTH ANY

: : identifies nerve root impingement caused

are met - 800) 918

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Spine Surgery  400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare     OR dislocation/subluxation, vertebral body fracture, dislodgement) film, CT and/or CT myelogram (i.e., subsidence, loosening, infection, f a is failed cervical disc arthroplasty implant is considered medically necessary Posterior cervical decompression with or without posterior cervical fusion following CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery  Performed for abuse) depressive disorder, A level Initial relief of symptoms following previou disc cervical s Greater than 12 weeks since the cervical disc arthroplasty demonstrating neural structure compression correlate with the patient’s symptoms or physical examination findings Recent (within 3 months) CT myelogram/MRI with when ailed cervical disc arthroplasty implant diagnosed by bsence of

-604. Radiculopathy   

ALL Subjective symptoms including Objective           following: Recent (within 6 months) MRI/C     patient’s symptoms the following:

5: Failed Cervical D B Place disability without concordant U as (NRS) Scale Rating (VAS)/Numeric Significant level of pain on a daily basis defined on aVisual Analog Scale Increased Inverted brachial radial reflex Tandem walking test Pathologic Babinski sign Hoffmann sign Hyperreflexia gait Ataxic Grip and release Myelopathic hand Clonus MRI/CT MRI/CT

of theof following criteria are met: nremitting radi unmanaged EITHER

B oulevard, physical examination findings including at least

when identifies stenosis with or without myelomalacia demonstrates spinal cord compression

muscle muscle chronic pain syndrome, secondary gain, drug and alcohol

of the following conditions: ALL significant behavioral health disorders (e.g., S luffton, cular and test tone or spasticity

of the following are met: objective physical examination findings resulting in

physical examination findings pain to shoulder girdle and/or upper extremity with isc Arthroplasty Implant Arthroplasty isc C 29 910 •(

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  Myelopathy when   

 following Less than clinically meaningful improvement       Objective physical examination findings including   requestis decompression for only Documentationof nicotine -     Objective   Subjective         following:  

B Place P without concordant objective physic Unremitting radicular pain to shoulder girdle and/or upper extremity Nerve root tension sign ( Shoulder Abduction Relief Sign Reflex changes Motor deficit (e.g., biceps, triceps weakness) Dermatomal sensory deficit chiropractic provider, osteopathic or allopathic physician 6for weeks surgery as evidenced by cotinine lab results of ≤ Patient has refrained from smoking for at least 6weeks prior to planned P E Provider Fine motor dysfunction (buttoning Upper/lower extremity weakness, numbness, or pain Frequent falls pathology New Increased Inver Tandem walking test Pathologic Babinski sign Hoffmann sign Hyperreflexia gait Ataxic Grip and release Myelopathic hand Clonus rescription strength analgesics, steroids, and/or NSAIDs for 6 weeks atient is a nonsmoker pidural steroid injection(s) - ted brachial radial reflex onset bowel or bladder d unless contraindicated:

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symptoms - directedexercise program

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare CMM      following sole indications withwithout or posterior fusion is Posterior cervical decompression (laminectomy, hemilaminectomy, andlaminoplasty CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery + + + + 63045 63015 63001 22600 22595 22590 a pur This CPT 22843 22842 22841 22614 uthori Degenerative disc disease Concordant discography Disc bulge with noneural impingement or cord compression on imaging Annular tears Signs andsymptoms with nocorrelation to imaging studies poses only ® -604.7 -604.6: Non g

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z a Arthrodesis, posterior atlas Arthrodesis, technique, posterior craniocervicalArthrodesis, technique, (occiput lateral recess recess vertebrallateral segment; cervicalstenosis]), single of spinaldecompression equina cauda cord, nerve and/or spinal [e.g., root[s], or Laminectomy, facetectomy and foraminotomy or(unilateral with bilateral thanmore 2vertebral segments; without equina, or discectomyfacetectomy, foraminotomy spinal stenosis), (e.g., decompressionLaminectomy withand/or spinal exploration cord and/or of cauda cervical segments; vertebral 2 or without equina, or discectomyfacetectomy, foraminotomy spinal stenosis), (e.g., 1 decompressionLaminectomy withand/or spinal exploration cord and/or of cauda to addition code primaryfor procedure) and hooks 7sublaminar wires); to 12vertebral segments separately (List in instrumentation segmental (e.g.,Posterior dual pedicle rodsfixation, with multiple codeto primary for procedure) and hooks 3sublaminar wires); to 6vertebral segments separately (List in addition instrumentation segmental (e.g.,Posterior dual pedicle rodsfixation, with multiple primary code for procedure) spinal byInternal wiringfixation of processes spinous separately (List in addition to procedure) Each additional vertebral segment separately(List in to addition code for primary segment posterior or Arthrodesis, singleposterolateral technique, level; cervical below C2 tion is r is tion B Place : Procedure (CPT : Procedure . A e lat e ny g

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Spine Surgery 6. 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 10. 9. 8. 7. 5. 4. 3. 2. 1. CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery on the individual’s policy or benefit entitlement structure as well as claimsprocessing rules. determinationfinal of reimbursement services for isdecision the of the health planis andbased list This may n +63295 + 63290 63285 63280 63275 63270 63265 63051 63050 63048 surgery Grabowski G, Cornett CA, Kang JD. 2011;93(8):780- Hsu AdvancedWK. techniques in cervical spine surgery. Journal of Bone and Joint Surgery. American Volume 2011;469(4):1035-41. instrumentation cost Hecht AC, Koehler SM, Laudone JC, Jenkins A, Qureshi S. Is intraoperative CT of posterior cervic 2010;66(3 Suppl):32- Hankinson TC, Anderson RC. Craniovertebral junction abnormalities in Down syndrome. Neurosurgery Surgery. Spine 2016; 41(8): 662-668. Guzman JZ, Feldman ZM, McAnany S, Hecht AC, Qureshi SA, Cho SK. Osteoporosis Cervical in Spin Neurosurgery 2011;68(3):622- Ghogawala Z, et al. Comparative effectiveness of ventral vs dorsal surgery for cervical spondylotic myelopathy. o Dvorak MF, et al. The surgical approach to subaxial cervical spine injuries: an evidence-based algorithmbased 2012;43(1):137- Celestre PC, et al. Minimally invasive approaches to the cervical spine. Orthopedic Clinics of North America 2005;353(4):392-9. Carette S, Fehlings MG. Clinical practice. Cervical radiculopathy. New England Journal of Medicine Campbell RM. Spine deformities in rare congenital syndromes: clinical issues. Spine 2009;34(17):1815 n the SLIC classification system. Spine 2007;32(23):2620- -604.8

--avoidance and management. Orthopedic Clinics of North America 2012;43(1):63- (List separately(List in to addition code primaryfor procedure) of dorsalreconstruction procedure primaryspinal elements, intraspinal following intraspinal neoplasm;Laminectomy biopsy/excision osteoplastic for of intradura intraspinal neoplasm;Laminectomy biopsy/excision combinedfor of extradural cervical intramedullary, intraspinal neoplasm;Laminectomy biopsy/excision intradural, for of cervicalextramedullary, biopsy/excision Laminectomy for intraspinal neoplasm;Laminectomy biopsy/excision cervical extradural, for of cervical Laminectomy excision lesion of otherfor intraspinal neoplasm, than intradural; cervical extradural; Laminectomy excision orfor evacuation of intraspinal than lesion neoplasm, other mini suture, bridging of application bone andnon graft withsegments; of the reconstruction posterior bony the(including elements cervical, decompressionLaminoplasty, with of the 2 spinal cord, or vertebral more segments; cervical, decompressionLaminoplasty, with of the 2 spinal cord, or vertebral more procedure) or lumbar thoracic, cervical, separately(List in to addition code primaryfor recess vertebrallateral segment; eachstenosis]), single additional segment, of spinaldecompression equina cauda cord, nerve and/or spinal [e.g., root[s], or fa Laminectomy, B Place : References ot be all inclusive and is not intended to be used for coding/billing purposes. The 8. 47.

l lesion, any level -effective and does it reduce complications? Clinical Orthopaedics and Related Research 8.

B oulevard,

- plates), when performed) cetectomy and foraminotomy or(unilateral with bilateral 30; discussion 630-1.

S luffton,

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 13. 12. 11. Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery 15. 14. 34. 33. 32. 31. 30. 29. 28. 27. 26. 25. 24. 23. 22. 21. 20. 19. 18. 17. 16. American Academy of Orthopedic Surgeons 2006;14(2):78- Kwon BK, Vaccaro AR, Grauer JN, Fisher CG, Dvorak MF. Subaxial cervical spine trauma. Journal of the junction. Neurosurgery 2010;66(3 Suppl):83-95. Krauss BledsoeWE, JM, Clarke MJ, Nottmeier EW, Pichelmann MA. Rheumatoid arthritisthe craniovertebral of laminectomy andfusion. Spine Journal 2006;6(6 Suppl):252S Komotar RJ, Mocco Kaiser J, MG. Surgical management of cervical myelopathy: indications and techniques for Bone Joint Surg Am. 2014: 96: 2049- Po for Machino M,Yukawa Y, Ito K, Inoue T, Kobayakawa A, Matsumoto T, Ouchida J, Tomita K, Kato F. Risk Factors Orthopedic Clinics of North America 2012;43(1):29-40 Lawrence BD, Brodke DS. Posterior surgery for cervical myelopathy: indications, techniques, and outcomes. systematicreview. European Spine Journal 2011;20(2):177- Zechmeister I, Winkler R, Mad P. Artificial total disc replacement versus fusion for the cervical spine: a Campbell's Operative Orthopaedics. 11th ed. Philadelphia, PA: Mosby Elsevier; 2008:1761- dislocations, Fractures, II. GW Wood Wang VY, Chou D. The cervicothoracic junction. Neurosurgery Clinics of North America 2007;18(2):365-71. 2009;151(3):269-76. Turgut M. Kl the multicenter, prospective AOSpine International Study of 479 patients. Neurosurgery. 2015 Nov 25. predictors of complications following surgery for the treatment of cervical spondylotic myelopathy: results from Tretreault L, Tan G, Kopjar B, Cote P, Arnold P, Nugaeva N, Barbagallo G, Fehlings Tracy JA, Bartleson JD. Cervical spondylotic myelopathy. Neurologist 2010;16(3):176-87. Journal 2011;20(9):1466-73. approach for cervical myelopathy dueto ossification Sun Q, et al. Do intramedullary spinal cord changes in signal intensity onMRI affect surgical opportunity and Neurosurgical Focus 2011;30(3):E8 posterior longitudinal ligament: considerations for approach selection and review of surgical outcomes. Shin JH, Steinmetz MP, Benzel EC, Krishnaney AA. Dorsal versus ventral surgery for cervical ossification of the pseudoachondroplasia. Journal of Pediatric Orthopedics 2007 Oct Shetty GM, Song HR, Unnikrishnan R, Suh SW, Lee SH, Hur CY. Upper cervical spine instability in Pa 1976). Apr 1 2005;30(7):756-759 myelopathy due to disc herniation: a comparative study of laminoplasty and anterior spinal fusion. Spine (Phila Sakaura H, Hosono N, Mukai Y, T, Ishii Iwasaki M,Yoshikawa H. Long-term outcome 2011;34(11):889. discectomy and fusion: four Sasso RC, Anderson PA, Riew KD, Heller JG. Results of cervical arthroplasty compared with anterior Surgery. American Volume 2006;88(7):1619-40. Rao RD, Gourab K, David KS. Operative treatment of cervical spondylotic myelopathy. Journal of Bone and Joint Ac Raizman NM, O'Brien JR, Poehling -Monaghan KL, Yu PseudarthrosisWD. of the spine. Journal of the American 3 ] National Hospital Discharge Database Analysis, all payers, all applicable states, 2009-2010. [ Context Link 1, 2, of Neurosurgery: Spine 2009;11(2):130- 41 Mummaneni PV, et al. Cervical surgical techniques for the treatment of cervical spondylotic myelopathy. Journal Spine 2009;11(2):119-29. and electroencephalography: does the test predict outcome after cervical surgery? Journal of Neurosurgery: Mummaneni PV, et al. Preoperative patient selection with magnetic resonance imaging, computed tomography, Orthopedic Clinics of North America 2012;43(1):75-87 M Neurosurgery:Spine 2009;11(2):157 - Matz PG, et al. Cervical laminoplasty for the treatment of cervical degenerative myelopathy. Journal of Neurosurgery. Aug 2, 2011. Cervical Laminoplasty versus Cervical Laminectomy and Fusion for Multi Manzano GR, Casella G, MY,Wang D ODCS, Levi AD. A Prospective, Randomized Trial Comparing Expansile olina CA,olina Gokaslan ZL, Sciubba DM. Diagnosis and management of metastatic cervical spine tumors. ademy of Orthopedic Surgeons 2009;17(8):494- or Outcome of Cervical Laminoplasty for Cervical Spondylotic Myelopathy Patients in with Diabetes. J -Feilippel syndrome in association with posterior fossa dermoid tumour. Acta Neurochirurgica B Place B oulevard, -year clinical outcomes in a prospective, randomized controlled trial. Orthopedics S luffton, and fracture-dislocations of the spine. In: Canale ST, Beaty JH, editors. 69. 55 C 29 910 •( 503. of the posterior longitudinal ligament? European Spine - 800) 918 89. 84. -267S. -Nov;27(7):782-7. 8924 -level Cervical Myelopathy.

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© 2018 eviCore healthcare. All rights reserved. Page 23 of 57 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com 6. 5. 4. 3. 2. 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 1. CMM CMM      medically necessary C CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery on the individual’s policy or benefit entitlement structure as well as claims processing rules of decision the is services for reimbursement of determination final This list may not be all inclusive and is not intended to be used for coding/billing purposes. The ervical microdiscectomy for a pur This +63035 +63043 uthori Neurosurgery: S Heary RF, et al. Cervical laminoforaminotomy for the treatment of cervical degenerative radiculopathy. Journal of America 2012;43(1):63 viii. -74, artery injuries Clinics of North America 2011;22(1):179-91. Grabowski G, Cornett CA, Kang JD. Esophageal and vertebral Decker RC. Surgical treatment and outcomes of cervical radiculopathy. Physical Medicine and Rehabilitation cervical spondylotic myelopathy. Spine 2010;35(5):537- Cunningham MR, Hershman S, Bendo Systematic J. review of cohort studies comparing surgical treatments for Series [Internet] American Association of Neuroscience Nurses. 2007 Cervical spine surgery.guidepreoperativeA to andpostoper 2012;43(1):137- Celestre PC, et al. Minimally invasive approaches to the cervical spine. Orthopedic Clinics of North America from degenerativefrom disorders. Spine Journal 2011;11(1):64- Bono CM, et al. An evidence- Degenerative disc disease Concordant discography Disc bulge with noneural impingement or cord compression on imaging Annular tears Signs andsymptoms with nocorrelation to imaging studies 63040 63020 CPT poses only -605. -605.5 -605.4: Non g uideline r ® z

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 12. 11. 9. 8. 7. Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery 20. 19. 18. 17. 16. 15. 14. 13. 10. Orthopedic Clinics of North America 2012;43(1):75-87, viii- Molina CA, Gokaslan ZL, 54. Miller et J, al. Manual therapy and exercise for neck pain: a systematic review. Manual Therapy 2010;15(4):334- Journal of Radiation Oncology, Biology andPhysics 2011;79(4):965- Lutz S, et al. Palliative radiotherapy for bone metastases: an ASTRO evid-basedence guideline. International radiographicand follow treat Jagannathan ShermanJ, JH, Szabo T, Shaffrey CI, Jane JA. The posterior cervical foraminotomy the in 2011;93(8):780- Hsu AdvancedWK. techniques in cervical spine surgery. Journal of Bone and Joint Surgery. American Volume Tracy JA, Bartleson JD. Cervical spondylotic myelopathy. Neurologist 2010;16(3):176-87 Journal of Neurosurgery 1997;87(1):41-3. Tomaras CR, Blacklock JB, Parker HarperWD, RL. Outpatient surgical treatment of cervical radiculopathy. Surgical treatment of cervical spondylodiscitis: areview of 30 consecutive patients. Spine 2012;37(1):e30- 2010;90(4):1128DOI:-33. 10.1016/j.athor Rueth N, et al. Management of cervical esophageal injury after spinal surgery. Annals of Thoracic Surgery of Bone and Joint Surgery. American Volume 2007;89(6):1360-78. Rao RD, et al. Degenerative cervical spondylosis: clinical syndromes, pathogenesis, and management. Journal Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD001466 Nikolaidis I, Fouyas IP, Sandercock PA, Statham PF. Surgery for cervical radiculopathy or myelopathy. Spine 2009;11(2):119 -29. and electroencephalography: does the test predict outcome after cervical surgery? Journal of Neurosurgery: Mummaneni PV, et al. Preoperative patient selection with magnetic resonance imaging, computed tomography, Ne of Mummaneni PV, et al. Cervical surgical techniques for the treatment of cervical spondylotic myelopathy. Journal Lippincott&2010:1975 Wilkins; - Williams CheeverJL, KH, editors. Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 12th ed. Philadelphia, PA: Management of patients with oncologic or degenerative neurologic disorders. In: Smeltzer SC, Bare BG, Hinkle ment of cervical disc/osteophyte disease: a single- urosurgery: Spine 2009;11(2):130-41. B Place 8. B oulevard, -up. Journal of Neurosurgery: Spine 2009;10(4):347 -56

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 4. 3. 2. 1. CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery 14. Gebara, 13. 12. 11. 10. 9. 8. 7. 6. 5. 25. 24. 23. 22. 21. 20. 19. 18. Goldberg 17. 16. 15. Spine Journal 2015: (15) 857- laser disc decompression versus conventional microdiscectomy insciatica: a randomized controlled trial. The den Berg-Huijsmans, Aneete A., Koes, Bart van Buchem,W., M. A., Arts, Mark P., Peul, Wilco C.. Percutaneous Brand A., Brouwer, Patrick 2016: (7) 1466: 1-9. Musculoskeletal Pain: Variability andInfluence of Sex andCatastrophizing. Frontiers in Psychology September Points for Mild, off Moderate, and Severe Pain on the Numeric Rating Scale for Pain Patientsin with Chronic Boonstra, AM, Stewart RE, Koke AJA, Oosterwijk RFA, Swann JL, Schreurs KMG, Sciphorst Preuper HR. Cut Techniques 2006;19(5):334 -7. Best NM, RC. Sasso Success and safety in outpatient microlumbar discectomy. Journal of Spinal Disorders and Microdiscectomy for Sciatica: A Randomized Controlled Trial. JAMA 2009; (302): 149-1 Leiden-The Hague Spine Inteverntion Prognostic Study Group(SIPS). Tubular Disckectomy vs Conventional Arts, Mark P., Brand R, Elske vanden Akker, M, Koes, Bart W., Baretls, Ronald H. M. A., Peul, C.Wilco for the on the numeric rating scale: a cut Gerbershagen HJ, Rothaug J, Kalkman CJ, Meissner DeterminationW. of moderate-to 13. 5- Eliyas JK, Karahalios D. Surgery for degenerative lumbar spine disease. DiseaseMonth-a- 2011;57(10):592 -606 Spine 2011;14(5):647-53. Desai A, et al. Outcomes after incidental durotomy during first management of chronic low back pain. Pain Physician 2009;12(1):109-35 Conn A, Buenaventura RM, Datta S, Abdi S, Diwan S. Systematic review of caudal epidural injections in the 2007;147(7):505-14 Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American evidence-based clinical practice guideline from the American Pain Society. Spine 2009;34(10):1066-77. Chou R, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: College of Physicians and the American Pain Society. Annals of Internal Medicine 2007;147(7):478-91 Chou R, et al. Diagnosis and treatment of low back pain: aj Provocative Discography. Spine 2006; 31(18):2115 - Carragee, Eugene etJ. al. A Gold Standard Evaluation of the “Discogenic Pain” Diagnosis Determinedas by Degeneration Changes in the Lumbar Disc: A Ten-year Matched Cohort Study. Spine, 2009;34(21): 2338-2345. Carragee, Eugene etJ. al. 2009 ISSLS Prize Winner: Does Discography Cause Accelerated Progression of sciatica: 5 Hague Spine Intervention Prognostic Study Group. Surgery versus prolonged conservative treatment for Lequin Ml B, Verbaan D, Jacobs, BrandWCH., R, Bouma GJ, Vandertop Peul,WP, for theWC Leiden -The injections lumbar in spinal stenosis.Spine. 2009;34(10):985- Koc Z, Ozcakir S, Sivrioglu K, Gurbet A, Kucukoglu S. Effectiveness of physical therapy and epidural steroid Journal of Neurosurgery: Spine 2007;6(4):327- a Centers for Disease Control and Prevention guideline - Kanayama M, Hashimoto T, Shigenobu K, Oha F, Togawa D. Effective prevention of surgical site infection using (LAIDBack) Study: baseline data. Spine (Phila Pa 1976) 2001; 26:1158. Jarvik JJ, Hollingworth HeagertyW, P, et al. The Longitudinal Assessment of Imaging and Disability of the Back cohort: clinical and imaging risk factors. Spine (Phila Pa 1976) 2005; 30:1541. Jarvik JG, Hollingworth HeagertyW, PJ, et al. Three-year incidence of low back pain in an initially asymptomatic systematic review. European Spine Journal 2011. Jacobs et al. SurgeryWC. versus conservative management of sciatica due to a lumbar herniated disc: a times, length of hospital stay, narcotic use and complications. Minimally Invasive Neurosurgery 2008;51(1):30-5. Harrington JF, French P. Open versus minimally invasive lumbar microdiscectomy: comparison of operative radiculopathy: a systematic review. Spine 2010;35(11):E488 Hahne AJ, Ford JJ, McMeeken JM. Conservative management of lumbar disc herniation with associated Randomized Clinical Trial. JAMA 2015: (313) 19: 1915- Won LA, Carragee E, Avins AL. Oral Steroids for Acute Radiculopathy Due to aHerniated Lumbar Disk: A Reviews 2007, (verified by Cochrane 2008 Oct), Issue 2. Art. No.: CD001350 Gibson JN, G.Waddell Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic 2008;25(2):E20. discectomy: comparison of minimally invasive discectom German JW, Adamo MA, Hoppenot RG, Blossom JH, Nagle HA. Perioperative results following lumbar Aneaesthesia June 2011: 107 (4): 619-26. -606.6 NV, Meltzer DE. Extraspinal findings on lumbar spine MR imaging. Radiology Case. 2009 Aug; 3(8): H, Firtch TyburskiW, M, Pressman A, Ackerson L, Hamilton L, Smith CarverW, R, Maratukulam A, -year results of arandomized controlled trial. BMJ Open 2013; 3: e002534. B Place : References B oulevard, , Ronald, Elske van den Akker 865. -off po S luffton,

int analysis applying four different methods. British Journal of C 29 9. 910 •( 2123. based antimicrobial prophylaxis lumbar in spine surgery. y andstandardy microdiscectomy. Neurosurgical Focus 1923. -van Marle,M, Jacobs, C. H.,Wilco Schenk, Barry, van - 800) 918 oint clinical practice guideline from the American the from guideline practice clinical oint -504 9. time -time lumbar discectomy. Journal of Neurosurgery: 8924

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 43. 42. 41. 40. 39. 38. 37. 36. 35. 34. 33. 32. 31. 30. 29. 28. 27. 26. Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery 45. 44. Campbell's Operative Orthopaedics. 11th Williams KD, Park AL. Lower back pain and disorders of intervertebral discs. In: Canale ST, Beaty JH, editors. Outcomes Research Trial (SPORT) Observational Cohort. JAMA Nov 2006: 296(20): 2451 Weinstein JN, et al. Surgical vs Nonoperative Treatment for Lumbar Disk Herniation: The Research Trial (SPORT): arandomized trial. JAMA; 2006; 296:22441-2450. Et JN. Weinstein Spine Patient Outcomes Research Trial (SPORT). Spine 2008;33(25):2789-800. Weinstein JN, et al. Surgical versus nonoperative treatment for lumbar disc herniation: four Sciences 2010;37(1):49-53. Admission and acute complication rate for outpatient lumbar microdiscectomy. Canadian Jo Canadian JournalofAnaesthesia 2010;57(7):694 Tran deQH, Duong S, Finlayson RJ. Lumbar spinal stenosis: abrief review of the nonsurgical management. 9. microdiscectomy in pediatric patients: a series of 6 patients. Journal of Neurosurgery. Pediatrics 2011;7(6):616- Thomas JG, Hwang SW, Whitehead CurryWE, DJ, Luerssen TG, A. Jea Minimally invasive lumbar implications for enhancing patient safety founded on evidence-based protocols. Spine 2006;31(13):1503-10. Rampersaud YR, et al. Intraoperative adverse events and related postoperative complications in spine surgery: decompressionlumbarfor spinal stenosis. JournalSpinal of Podichetty VK, Spears J, Isaacs RE, Booher Biscup J, RS. Complications associated with minimally invasive 2007;356(22):2245-56. Peul et al.WC, Surgery versus prolonged conservative treatment for sciatica. New England Journal of Medicine herniation: two year results of a randomised controlled trial. BMJ. 2008 336(7657):1355-8. Peul etW.C. al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc NASS Coverage Policy Recommendations, Lumbar La NASS Coverage Policy Recommendations, Laser Spine Surgery, 2014. NASS Coverage Policy Recommendations, Endsocopic Discectomy, 2014. NASS Coverage Policy Recommendations, Lumbar Discectomy, 2014. Disks. AJNR Am J Neuroradiol 2002; 23:1105. Munter FM, BA,Wasserman HM,Wu Yousem DM. Serial MR Imaging of Annular Tears in Lumbar Intervertebral McGill, C.M. Industrial back problems. Journal of Occupational Medicine, 10, 1740- Research (SPORT). Trial Outcomes Spi versus Non-Operative Treatment for Lumbar Disc Herniation: Eight Lurie JD, Tosteson TD, Tosteson ANA, Zhao MorganW, TS, Abdu HerkowitzWA, H, Weinstein JN. Surgical 1996. Last Review: 2015. Accessed on Low back pain. ACR Appropriateness Criteria® Journal of Family Practice 2011;60(8):490 Young K, Brown R, Kaufmann L. Clinical inquiries. When is discectomy indicated for lumbar disc disease? Winters ME, Kluetz P, Zilberstein BackJ. pain emergencies. Med Clin North Am. 2006;90(3):505-523. B Place

al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes B oulevard, S luffton, ne Jan 2014.: 39(1): 3-16. May 22, 2018. ed. Philadelphia, PA: Mosby Elsevier; 2008:2159- . C 29 [Internet] American College of Radiology (ACR). Date of Origin: -703.DOI: 10.1007/s12630-010 910 •( minotomy - 800) 918

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 5. 4. 3. 2. 1. CMM C Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery individual’s policy or benefit entitlement structure as well as claims processing rules. determination of reimbursement for services theis decision of the health plan and is based on the This list may not be all inclusive and is not intended to be used +22870 +22868 : Procedure (CPT MM-608.5: Procedure a pur This 63048 63047 63017 63012 63011 63005 22869 22867 CPT uthori surgical therapy for chronic low pain. back Annals of the Rheumatic Diseases 2010;69(9):1643-8 Brox JI, Nygaard OP, Holm I, Keller A, Spine Surgery 2015;9. stabilization after decompressionfor lumbar spinal stenosis:yearfour assessement. a International Journalof Bae HW, Lauryssen C, Maislin G, et al. Therapeutic sustainability and durability of coflex interlaminar 2016;79(2): 169- coflex interlaminar stabilization vs instrumented fusion in patients with lumbar stenosis. NeuroSurgery Bae HW, Davis RJ, Lauryssen C, et al. Three -yer follow Manual Therapy 2011;16(4):308-17 Backstrom KM, JM,Whitman Flynn TW. Lumbar spinal stenosis 2011;261(3):681-4. And poses o g -608.6 reisek G, Hodler J, Steurer Uncertainties J. thein diagnosis of lumbar spinal stenosis. Radiology ® uideline r

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a tion is r thoracic, or lumbar (List separately addition in to code primary for procedure) recess stenosis]), single vertebral segment; each additional segment, cervical, decompression spinal of cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral Laminectomy, facetectomy andforaminotomy (unilateral or bilateral with recess stenosis]), single vertebral segment; lumbar decompression spinal of cord, cauda equina and/or nerve root(s), [e.g.,Spinal or lateral Laminectomy, facetectomy andforaminotomy (unilateral or bilateral with than 2vertebral segments; lumbar equina, without facetectomy, foraminotomy or discectomy (e.g., stenosis), spinal more Laminectomy with exploration and/or decompres procedure) decompression cauda of equina and nerve roots for spondylolisthesis, lumbar type (Gill Laminectomy with removal abnormal of facets and/or pars inter vertebr equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1or 2 Laminectomy with exploration and/or decompression spinal of cord and/or cauda vertebral segments; lumbar, except spondylolisthesis for equina, without facetectomy, foraminotomy or discectomy (e.g., stenosis), spinal 1or 2 Laminectomy with exploration and/or decompression spinal of cord and/or cauda second level (List separately addition in to code for primary procedure) open decompression or fusion, including image guidance when performed, lumbar; Insertion of interlaminar/interspinous process stabilization/distraction device, without single level open decompression or fusion, including image guidance when performed, lumbar; Insertion of interlaminar/interspinous process stabilization/distracti second level (List separately addition in to code for primary procedure) fusion, including image guidance when performed, with opendecompression, lumbar; Insertion of interlaminar/interspinous process stabilization/dist single level fusion, including image guidance when performed, with opendecompression, lumbar; I nsertion of interlaminar/interspinous process stabilization/distraction device, without nly B Place : References . A e 81. lat e ny g al segments;al sacral quir e s to the to s B oulevard, iven

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 35. 34. 33. 32. 31. Nandakumar A, Clark NA, Peehal JP, et al. The increase in dural sac area is maintained at 2 years after X 30. 29. 28. 17. 16. 15. 14. 13. 12. 11. Conn 10. 9. 8. 7. 6. Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery 27. 26. 25. 24. 23. 22. 21. 20. 19. 18. NASS Coverage Policy Recommendations, Lumbar Discectomy, 2014. NASS Coverage Policy Recommendations, Laser Spine Surgery, 2014. NASS Coverage Policy Recommendations, Interspinous Fixation with Fusion, 2014. NASS Coverage Policy Recommendations, Interspinous Devices without Fusion, 2014. N TheSpine Journal 2010;10:762 -8. implantation for the treatment of spinal stenosis with no significant alteration in lumbar spine range of movement. prospective, randomized, controlled trial. International Journal of Spine Surgery 2016;10(6). compared with decompression andfusion for the treatment of lumbar spinal stenosis: 5-year follow Musacchio M, Lauryssen C, Davis RJ, et al. Evaluation of decompressionandinterlaminar stabilization decompression for lumbar spinal stenosis: randomized controlled trial. BMJ 2013;347. Moojen Arts MP,WA, Jacobs WCH, et al. Interspinous process device versus standard conventional surgical stenosis. Fu KM, et al. Morbidity and mortality in the surgical treatment of 10,329 adults with degenerative lumbar 2009;3(2): 59-67. Errico TJ, Kamerlink JR, Quirno M, et al. Survivorship of coflex interlaminar Eliyas JK, Karahalios D. Surgery for degenerative lumbar spine disease. DiseaseMonth-a- 2011;57(10 ):592 Association 2010;303(13):1259-65. charges associated with surgery for lumbar spinal stenosis in older adults. Journal of the American Medical Deyo RA, MirzaMartin SK, BI, Kreuter GoodmanW, DC, Jarvik JG. Trends, major medical complications, and SPINE 2013;38(18): 1529 -39. decompression and instrumented spinal fusion for spinal stenosis and low Davis RJ, Errico TJ, Bae H, et al. Decompression and coflex interlaminar st Darouiche RO. Spinal epidural abscess. New England Journal of Medicine 2006;355(19):2012-20. 11th ed. Philadelphia, PA: Mosby Elsevier; 2008:2273 - Curlee PM. Other disorders of the spine. In: Canale ST, Beaty JH, editors. Campbell's Operative Orthopaedics. management of chronic low back pain. Pain Physician 2009;12(1):109-35. evidence-based clinical practice guideline from the American Pain Society. Spine 2009;34(10):1066-77. Chou R, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an 2007;147(7):505-14 Pain Society/American College of Physicians clinical practice guideline. Annals Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American College of Physicians and the American Pain Society. Annals of Internal Medicine 2007;147(7):478-91 Chou R, et al. Diagnosis and treatment of low back pain: ajoint clinical practice guideline from the American statement of the Global Spine Tumour Study Group. European Spine Journal 2010;19(2):215-22. Choi D, et al. Review of metastatic spine tumour classification and indications for surgery: the consensus the spine patient outcomes research trial (SPORT). Spine (Phila Pa 1976) 2015;40(2) Lurie JD, Tosteson TD, Tosteson A, et al. Long -term outcomes of lumbar spinal stenosis: eight 15; 40(2):2015 Jan77- decompression versus X Lonne G, Johnsen LG, Rossvoll I, Andresen H, Storheim K, Zwart JA, Nygaard OP. Minimially invasive stenosis.Asian Spine Journal 2014;8(2): 161-169. Kumar N, Shah SM, Ng YH, et al. Role of coflex an as adjunct to decompress guidlines for multidisciplinary spine care [Internet] North American Spine Society. 2011 DS, et Kreiner 2009;29(2):146- children andyoung adults:meta -analysis a of observational studies. Journal of Pediatric Orthopedics Klein G, Mehlman CT, McCartyM. Nonoperative treatment of spondylolysis and grade I spondylolisthesis in Journal of Neurosurgery: Spine 200 a Centers for Disease Control and Prevention guideline- Kanayama M, Hashimoto T, Shigenobu K, Oha F, Togawa D. Effective prevention of surgical site infection using EuropeanSpine Journal 2008;17(3):327-35. Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. interspinous device was implanted. NeurosurgJ Spine 2006;5: 500- Hsu KY, Zucherman JF, Hartjen CA, et al. Quality of life of lumbar stenosis 2016. interlaminar stabilization- Guyer R, Musacchio M, Cammisa FP, et al. ISASS recommendations/coverage criteria for decompression with stenosis: clinical study. World Neurosurgery2016;95: 556 -64. Ghany Amer A,WA, Saeed K, et al. Evaluation of interspinous spacer outcomes in degenerative lumbar canal ASS Coverage Policy Recommendations, Endsocopic Discectomy, 2014.

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JournalNeurosurgery: of Spine 2010;12(5):443 -6. B Place al. Diagnosis and treatment of degenerative lumbar spinal stenosis. clinical Evidence-based 56. B oulevard, 85. -Stop lumbarin spinal stensosis: arandomized controlled multicenter study. Spine coverage indications, limitations, and/or medical necessity. Published November 10, S luffton, 7;6(4):327- C 29 9. 910 •( 352. based antimicrobial prophylaxis lumbar in spine surgery. - 800) 918 7. 8924 -grade degenerative spondylolisthesis. -treated patients whom in the X STOP -interspinous implant. SAS Journal abilization comparedwith ion forion symptomaticlumbar spinal of Internalof Medicine : 63

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Spine Surgery 58. 57. 56. 55. 54. 53. 52. 51. 50. 49. 48. 46. 60. 59. 47. 45. 44. 43. 42. 41. 40. 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 39. 38. 37. 36. Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery Spine Patient Outcomes Research Trial. Spine 2010;35(14):1329-38 Weinstein JN, et al. Surgical versus nonoperative treatment for lumbar spinal stenosis four stenosis: a systematic review and - meta A,WU Zhou Y, QL, Li et al. Interspinous spacer versus traditional decompressive surgery for lumbar spinal Lumbar Spinal Stenosis. N Engl Med J 2008; 358: 749- 810. Boden S, Hilibran A, Goldberg H, Berven S, An H for the SPORT tors. Surgical versus Nonsurgical Therapy for Weinstein JN, Tosteson TD, Lurie JD, Tosteson ANA, Blood E, Hanscom B, Herkowitz H, Cammisa F, Albert T, rnalJou of Bone and Joint Surgery. American Volume 2009;91(6):1295- four Weinstein JN, et al. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. spondylolisthesi Watters et al.WC, An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar laminectomy. Journal of Neurosurgery: Spine 2005;3(2):129- Canadian JournalofAnaesthesia 2010;57(7):694 Tran deQH, Duong S, Finlayson RJ. Lumbar spinal stenosis: abrief reviewo. of the nonsurgical management. Thome C, et al. Outcome after less following insertion of anovel interspinous process distraction device. Spine 2005;30(23): 2677-82. Siddiqui M, Nicol M, Karadimas E, et al. The positional magnetic resonance imaging changes in the lumbar spine stenosis. SPINE 2006;31(25): 2958- Siddiqui M, Karadimas E, Nicol M, et al. Influence of X Published online Jan 26, 2018. compare the performance of decompression with and without interlaminar stabilization. NeurosurgJ Spine 2017. Schmidt Frankes, J, Rauschmann M, et al. Prospective, randomized, multicenter study with 2-year f of Neurosurgery: Spine 2010;13(5):589-93 Sansur CA, et al. Morbidity and mortality the in surgical treatment of 10,242 adults with spondylolisthesis. Journal Eur Spine J 2015;24: 2228-2235. device versus decompression alone in patients with lumbar spinal stenosis and back pain: a cross registry study. Roder C, Baumgartner B, Berlemann U, et al. Superior outcomes of decompression with an interlaminar dynamic Tech implantation of an interspinous device for lumbar spinal stenosis: aprospective controlled study. Spinal J Disord Richter A, Halm HF, Hauck M, al. et Two Sep 4; 9: CD010328. microdiscectomy/open discectomy for symptomatic lumbar disc herniation. Cochrane Database Syst Rev. 2014 Journal of Surgery 2017;39: 57-64. spinal stenosis (LSS): a systematic review and meta-analysis of randomized controlled trials. International Zhao X, Ma Ma J, X, et al. Interspinous process devices (IPD) alone versus decompression surgery for lumbar minimum 5 with decompression and posterior lumbar interbody fusion for the treatment of lumbar degenerative disease: a Yuan Su Q, LiuW, T, et al. Evaluation of coflex interspinous stabilization following decompression compared patients. Eur Spine 2010;19:J 283-9 decompressive surgery in lumbar spinal stenosis? One-year follow upof aprospective case control study of 60 Richter A, Schutz C, Hauck M, et al. Does an interpsinous device (Coflex™) improve the outcome of Rasouli MR, Rahimi-Movaghar V, Shokraneh F, Moradi Bone Joint Surg [Br]. 1999;81- Porchet F, Vader JP, Larequi A review. Curr RevMusculoskelet Med 2017;10: 189-98. Pintauro M, in SPORT.in Spine (Phil Pa 1976) 2012;37(21): 1791- Pearson A, Lurie TostesonJ, T, et al. shouldWho have surgery for spinal stenosis?: treatement effect predictors a comparative effectiveness study. The Spine Journal 2014;14: 1484-92. Patil CG, Sarmiento JM, Ugiliweneza B, et al. Interspinous device versus laminectomy for lumbar spinal stenosis 2015;8: 657-662. lumbarspinal stenosis: durablethree Patel VV, Nunley PD, Whang PG, et al. Superion® interspinous spacer for treatment of moder interspinous U (Coflex™). Korean J Neurosurg 2009;46: 292 Park S, Park spinal fusion olderin patients with spinal stenosis and spondylolisthesis. Neurosurg Focus 2014;36(6). Ong KL, Auerbach JD, Lau E, et al. Perioperative outcomes, complications, and costs associated with lumbar D NASS Coverage Policy Recommendations, Lumbar Interspinous Device without F NASS Coverage Policy Recommendations, Lumbar Interspinous Device without Fusion. ecompression, 2018. -year results thein Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts.

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 15. 14. 13. 12. 11. 10. 4. 3. 2. 1. CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery 27. 26. 25. 24. 23. 22. 21. 20. 19. 18. 17. 16. 9. 8. 7. 6. 5. invasive sacroiliac joint fusion: aprospective study. Med Devices Evid Res. 2013; 6: 219- Radiofrequency Deneravation. Reg Anesth Pain Med. 2009; 34(3): 206- Cohen SP, Strassels SA, Kurihara C, et al. Outcome Predictors for Sacroiliac Joint (Lateral Branch) using the iFuse Implant System. Med Devices Evid Res. 2015; 8: 485-492. Cher DJ, Reckling CapobiancoWC, RA. Implant survivorship analysis after minimally invasive sacroiliac fusion inas other lumber spinal conditions. Med Devices Evid Res. 2015; 8: 395- Cher DJ, Reckling QualityWC. of life in preoperative patients with sacroiliac dysfunction is at least as depressed Cher DJ, Polly D, Berven S. Sacroiliac joint pain: burden of disease. Med Devices Evid Res. 2014; 7: 73-81. Outcomes Res CEOR 2016; 8: 1-14. Cher DJ, Frasco MA, Arnold RJ, Polly DW. Cost SpingerPlus. 2015; 4(1): 570. persistent post Capobianco R, Cher D. Safety andeffectiveness of minimally invasive sacroiliac joint fusion women in with screw instrumentation: a new technique. SpinalJ Belanger TA, Dall BE. Sacroiliac arthrodesis using a posterior midline fascial splitting approach and pedicle options.Evid -Based Spine-Care J. 2010; 1(03): 35-44. Ashman B, Norvell D, Hermsmeyer Chronic J. sacroiliac joint pain: fusion versus denervation as treatment Res. 2013; 2013(5): 575- Medicare population: potential economic implications of a new minimally to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States Ackerman S, Cummings Polly J, D, Knight T, Schneider K, Holt T. Comparison of the costs of nonoperative care Journal of Spinal Disorders and Techniques 2008; 21(5): 359 KhayerAl- A, Hegarty Hahn J, D, Grevitt MP. Percutaneous sacroiliac joint arthrodesis: a novel technique. injection/arthrography technique. Part II: Clinical evaluation. Spine 1994; 19: 1483- Fortin JD, Aprill CN, Ponthieux B, Pier SacroiliacJ. joint pain referral maps upon applying a new BoneJ Joint Surg AM. 2015; 97(11): 932- 936. Eno JJ, Boone C, Bellino M, Bishop The J. Prevalence of Sacroiliac Joint Degeneration in Asymptomatic Adults. Indian Orthop. J 2013; 47(5): 437-442. Endres S, Ludwig E. Outcome of distraction interference arthrodesis of the sacroiliac joint for sacroiliac arthritis. Duhon BS, Cher D, K,Wine Lockstadt H, Kovalsky D, Soo C 6(3): 257 -269. Titanium Implants for Minimally Invasive Sacroiliac Joint Fusion: A Prospective Study. Glob Spine J. 2016; Duhon BS, Cher DJ, KD,Wine Kovalsky DA, Lockstadt H, on behalf of the SIFI Study Group. Triangular 10: Article 13. 2 Fusion: Joint Sacroiliac Invasive Duhon B, Bitan F, Lockstadt H, Kovalsky D, Cher D, Hillen T. Triangular Titanium Implants for Minimally fusion. DePalma MJ, Ketchum JM, Saullo TR. Etiology of chronic low pain back in patients having undergone lumbar from the prospective randomized controlled iMIA trail. Acta Neurochir (Wien). Nov 2016; 158(11): 2219 -2224. Dengler SturessonJ, B, Kools D, et al. Referred leg pain originating from the sac 537-550. Management vs. Minimally Invasive Surgical Treatment for Sacroiliac Joint Pain. Pain Physician. 2017; 20: Dengler KoolsJ, D, Pflugmacher R, et al. 1-Year Results of a Randomized Controlled Trial of Conservative Management of Pain Originating from the Sacroiliac Joint: A Pooled Analysis. Spine. March 2017. De Ann Surg Innov Res. 2013; 7(1): 12. Cummings J Jr, Capobianco RA. Minimally invasive sacroiliac joint fusion: one-year outcomes in 18 patients. 279-288. study evaluating Cohen SP, Hurley RW, Buckenmaier CC, Kurihara C, Morlando B, Dragovich A. Randomized placebo of sacroiliac arthrodesis for the disorders of the sacroiliac joint. Spine Journal 2005. 5(5): 520-528. Buchowski JM, Kebaish KM, Sinkov V, Cohen DB, Sieber AN, Kostuik JP. Functional and radiographic outcome November 2016. treated by arthrodesis using a triangular implant system. Technol Health Care Off EurJ Soc Eng Med. Bornemann R, Roesler PP, Straus A, et al. 2-year clinical results of patients with sacroiliac join Disord. 1998; 11(4): 341- Boradhurst NA, Bond MJ. Pain provocation tests for the assessment of sacroiliac joint dysfunction. Spinal J Blue Cross Blue Shield Association. Diagnosis and Treatment of Sacroiliac Joint Pain. 1987; (217): 266-80. Bernard TN, Kirkaldy ngler DuhonJ, B, P,Whang et al. Predictors of Outcome Conservativein and Minimally Invasive Surgical -611.6: References PainMedicine 2011. 12(5): 732-739. B Place - partum posterior pelvic girdle pain: 12-month lateral branch radiofrequency denervation for sacroiliac pain. Anesthesiology. 2008; 109(2): - Willis Willis RecognizingWH. specific characteristics of nonspecific low pain. back Clin Orthop. B oulevard, 587. 345. S luffton, -Year Follow

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 39. 38. 37. 36. 35. 34. 33. 32. 31. 30. 29. 28. Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery 44. 43. 42. 41. 40. 56. 55. 54. 53. 52. 51. 50. 49. 48. 47. 46. 45. similarly safe and effective? Clin Orthop. 2014; 472(6): 1831-1838. Ledonio CGT, Polly DW, Swiontkowski MF.Minimally invasive versus open sacroiliac joint fusion: are they Joint Pathology. Am PhysJ Med Rehabil. 2007; 86(1): 37-44. Irwin RW, T,Watson Miick RP, Ambrosius Age, BodyWT. Mass Index, andGender Differences in Sacroiliac Sacroiliac Joint Fusion. July 2016. International Society for the Advancement of Spine Surgery (ISASS) Policy Statement – Invasive Kube RA, Muir JM. Sacroiliac Joint Fusion: One Year Clinical and Radiographic Results Following Minimally triangular titanium implants: an independent review. Open Orthop J. 2013; 7: 51-56. Kim JT, Rudolf LM, Glaser JA. Outcome of percutaneous sacroiliac joint fixation with porous plasma-coated 91(5): 627-631. anchorage screws: clinical and radiological outcome. Journal of Bone and Joint Surgery British Volume 2009; Khurana A, Guha AR, Mohanty K, Ahuja S. Percutaneous fusion of the sacroiliac joint with hollow modular sacrum. Journal of Spinal Disorders and Techniques 2003; 16(1): 96-99. Katz V, Schofferman ReynoldsJ, J. The sacroiliac joint: a potential cause of pain after lumbar fusion to the n. Asian Spine Fusio J. 2017; 11(1):Joint 120-126. Kancherla VK, McGowan SM,Audley BN, Sokunbi G, Puccio ST. Patient Reported Outcomes from Sacroiliac transarticularapproach.Surg.Article Int Spine 2015; J 9: 40. Heiney J, Capobianco R, Cher D. Systemic review of minimally invasive sacroiliac joint fusion using a lateral comparison of perioperative measures and clinical outcomes. Ann Surg Innov Res. 2013; 7(1): 14. Graham Smith A, Capobianco R, Cher D, et al. Open versus minimally invasive sacroiliac fusion: a multi 2013; 57(4): Gaetani P, Miotti D, Risso A, et al. Percutaneous arthrodesis of sacroiliac joint: a pilot study. Neurosurg J Sci. technique. Part I. Asymptomatic volunteers. Spine. 1994; 19: 1475- Dwyer S,JD, Fortin J. AP, Joint:referra pain Pier West Lindsey D, Perez Motion: A Finite Element Study. Int Spine J Surg. 2015; 9: 64. Lindsey DP, Kiapour A, Yerby SA, Goel VK. Sacroiliac Joint Fusion Minimally Affects Adjacent Lumbar Segme nt fusion: findings using dual sacroiliac joint blocks. Pain Medicine 2011; 12(4): 565-570. Liliang PC, Lu K, Liliang CL, Tsai YD, KW, ChenWank HJ. Sacroiliac joint pain after lumbar and lumbosacral 34(9): 896-900. triamcinolone acetonide in the treatment of sacroiliac joint dysfunction without spondyloarthropathy. Spine 2009; Liliang PC, Lu K, HC,Weng Liang CL, Tsai YD, Chen HJ. The therapeutic efficacy of sacroiliac joint blocks with invasive sacroiliac joint fusion. Med Devices Evid Res. 2014; (7): 187- Ledonio C, Polly D, Swiontkowski MF, Cummings ComparativeJ. effectiveness of open versus minimally NASS Coverage Policy Recommendations. Percutaneous Sacroiliac Joint Fusion. 2015. Res. 2013; 6: 77-84. System: mina Miller L, Reckling BlockWC, JE. Analysis of postmarket complaints database for the iFuse SI joint Fusion Joint Fusion system. Medical Devices 2014; 7; 125- Miller, LE, Block JE. Minimally invas Based Spine Care Journal 2012; 3(3): 21-8. McGuire RA, Chen Z, Donahoe K. Dual fibular allograft technique for sacroiliac joint arthrodesis. Evidence anchorage screws: a prospective outcome study. European Spine Journal 2013; 22(10); 2325-2331. Mason, LW, Chopra I, Mohanty K. The percutaneous stabilization of the sacroiliac joint with hollow modular provocation tests in 54 patients with low back pain. Spine. 1996; 21(16): 1889- Maingne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block andvalueof sacroiliac pain Lorio MP. ISASS policy statement 2014; 8: Article 25. Lorio M, Rashbaum R. ISASS Policy Statement – 6. 1- Surgeonin Population of ISASS andSMISSMembership. The Open Orthopaedics Journal. January 2014; 8(1): Lorio M, Polly D, Ninkovic I, et al. Utilization of Minimally Invasive Surgical Approach for Sacroiliac Joint Fusion (L36406) Local Coverage Determination (LCD): Minimally for the treatment of back pain (L36000) Local Coverage Determination (LCD): Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint analysis. Eur Spine MarchJ. 2016: 1-8. Lingutla KK, Pollock R, Ahuja S. Sacroiliac joint fusion for low pain: back a systematic review andmeta- 2014; (7): 131-137. sacroiliac joint fusion –

Sacroiliac Joint Fusion Surgery. Open Orthop J. 2016; 10(1). 297 B Place imally invasive treatment for degenerative sacroiliitis and sacroiliac disruption. Med Devices Evid -301. -Orribo L, Rodriquez B oulevard, an vitroin biomechanical analysis of initial and cycled properties. Med Devices Evid Res. S luffton, – – ive arthrodesis for chronicsacroiliac jointdysfunction SImmetry usingthe SI minimally invasive sacroiliac joint fusion (July 2016). 2016. -Martinez N, et al. Evaluation of a minimally invasive procedure for C 29 -Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint. 910 •( Minimally 130. l mapsl upon applying a new injection/arthrography - 800) 918

Invasive Sacroiliac Joint Fusion. Int Spine J Surg. 8924 82. 193. 1892.

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Spine Surgery 69. 68. 67. 66. 65. 64. 63. 62. 61. 78. 77. 76. 75. 74. 73. 72. 71. 70. 60. 59. 80. 79. 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 58. 57. Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery 85. 84. 83. 82. Soriano -Baron H, Lindsey DP, Rodriguez 81. Rudolf L, Capobianco R outcomes. Open Orthop Journal 2012; 6(1):495 -502. Rudolf L. Sacroiliac joint arthrodesis 2013;J. 7: 163-168. Rudolf L. MIS Fusion of the SI Joint: Does Prior Lumbar Spinal Fusion Affect Patient Outcomes? Open Orthop Spine Surg. 2016; 29(2): 42- Rashbaum RF, Ohnmeiss DD, Lindley EM, Kitchel SH, Patel VV. Sacroiliac Joint Pain and Its Treatment. Clin Neurosurg. 2017; 101: 493-497. Coated Screw: Preliminary 1- Rappaport LH, Luna IY, Joshua G. Minimally Invasive Sacroiliac Joint Fusion Using a Novel Hydroxyapatite- Article2016; 10: 28. Invasive Sacroiliac Joint Fusion vs Non-Surgical Management for Sacroiliac Joint Dysfunction. Int SpineJ Surg. Polly DW, Swofford J, Whang PG et al. Two- Outcomes. Neurosurgery. 2015; 77(5): 674-691. Using Triangular Titanium Implants vs Nonsurgical management 12 for Sacroiliac Joint Dysfunction: Polly DW, Cher DJ, KD,Wine et al. Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion Respons Predict Block Joint Polly D, Cher D, PG,Whang Frank C, Sembrano J. for the INSITE Study Group. Does Level of Response to SI branch neurotomy for chronic sacroiliac joint pain. Pain Med Malden Mass. 2012; 13(3): 383-398. Patel N, Gross A, Brown L, Gekht G. A randomized, placebo Treatment for Sacroiliac Region Pain. Pain Pract Off J World Inst Pain. January 2015. Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine. 1995; 20(1): 31- Long Fusion thein Sacrum in Adult Spine Deformity. Hosp Spec Surg J. 2013; 10(1): 30 Schroader JE, Cunningham ME, Ross T, Boachie-AdjeiO. Early Results Sacro of diagnostic evaluation. Spine Journal 2003; 3(5): 400-403. Schofferman J, Reynolds HerzogJ, R, Covington E, Dreyfuss P, O’Neill C. Failed back surgery: etiology and sacroiliac fusion. Spine NovJ. 2016; 16(11): 1324- Schoell K, Buser Z, Jakoi A, et al. Postoperative complications in patients undergoing minimally invasive transiliac sacroiliac Sachs invasive D, Kovalsky D, Redmond A, minimally et al. after Durable intermediate outcomes to long-term series of triangular implants: a multicenter, patient Sachs D, Capobianco R, Cher D, et al. One-year outcomes after minimally invasive sacroiliac joint fusion with a Surgical Innovation and Research 2012; 6(13); 1-4. Sachs D., Orthop. 2013. Sachs D, Capobianco R. Minimally invasive sacroiliac joint fusion: one-year outcomespatients. 40 in Adv 187.2013: Description of Technique. International Society for the Advancement of Spine Surgery. Vancouver, BC Canada; Sachs D. Minimally Invasive versus Open Sacroiliac Joint Fusion: A Comparison of Process Measures and using triangular implants. Open Orthop J. 2014; 8: 375- Patel N. Twelve- Joint Dysfunction. BoneJ Joint Surg Am. 2017; 99: 2027 -36. Ou comparison. Annals of Surgical Innovation and Smith AG, Capobianco R, Cher D, et al. Open versus minimally invasive sacroiliac joint fusion: a multi Sembrano J F Ohtori S, Sainoh T, Takaso M, et al. Clinical Incidence of Sacroiliac Joint Arthritis and Pain after Sacropelvic sacroiliac pain [IPG578]. 2017; https://www.nice.org.uk/guidance/ipg578. National Institute for Health and Care Excellence. Minimally invasive sacroiliac joint fusion surgery for chronic Conservative Management. Eur Spine J. 2017; 26( Randomized Controlled Trial of Minimally Invasive SI Joint Fusion with Triangular Titanium Implants vs. St exercises for pelvic girdle pain after pregnancy: a randomized controlled trial. Spine. 2004; 29(4): 351-359. Stuge B, Laerum E, Kirkesola G, Volestad N. The efficacy of a treatment program focusing on specific stabilizing confirmed chronic sacroiliac pain. Evid Spiker LawrenceWR, BD, Raich Al, Skelly AC, Brodke DS. Surgical versus injection treatment for injection- PMID 28377863. Spain K, Holt T. Surgical revision after sacroiliac joint fixation or fusion. Int J. Spine Surg. Apr 2017; 11:5. Range of Motion: Posterior vs Trans ixation for Spinal Deformity. Yonsei Med 2012; J. 53(2): 416. uresson B, Kools D, Pflugmacher R, Gasbarrini A, Prestamburgo D, Dengler SixJ. -Yang DC, York PJ, Kleck CJ, Patel VV. Current Concepts Review: Diagnosis and Management of Sacroiliac

Capobianco R. One year successful outcomes for novel sacroiliac joint arthrodesis system. Annals of N, Polly DW. How often is low back pain not coming from the back? Spine. 2009; 34(1): E27-E32. B Place MonthFollow joint fusion using triangular titanium implants. Med Devices Evid Res. 2016; 9: 213-222. B oulevard, . Five . e to SI Joint Fusion? Int Spine J Surg. 2016; 10: Article 4. 48. Year Clinical and Radiographic Results of a 2-Year Prospective World Study. -year clinical and radiographic outcomes after minimally invasive sacroiliac fusion -Up of aRandomized Trial Assessing Cooled Radiofrequency Denervation as a S luffton, -articular. Spine. 2015; 40(9): E525-E530. – – -Based Spine -Car MIS technique with titanium implants: report of the first 50 patients and -Martinez N, et al. The Effect of Implant Placement onSacroiliac Joint C 29 Year Outcomes from a Randomized Controlled Trial of Minimally Research 2013; 7: 14. 910 •( - level analysis. Med Devices Evid Res. 2014. 7: 299- 1332. PMID 27349627. 3): 708- 3): 383. e J. 2012; 3(4): 41-53. - 800) 918 719. -controlled study to assess the efficacy of lateral 8924 -Iliac Joint Fixation Following - Month Outcomes from a

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 89. 88. 87. 86. Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery 94. 93. 92. 91. 90. Experience in aProspective Series with 24Patients. Spine. J 2014; 3(5). Vanaclocha VV, Verdu - Comparative Case Series. Neurosurgery. April 2017. Fusion, Radiofrequency Denervation, and Conservative Management for Sacroiliac Joint Pain: 6-Year Vanaclocha V, Herrera JM, Siz sacroiliac joint pain: a systematic review. Pain. J 2009; 10(4): 354 Szadek KM, van der P,Wurff van Tulder MW, Zuurmond PerezWW, RSGM. Diagnostic validity of criteria for joint in humans. Reg Anesth Pain Med. 2008; 33(1): 36-43. Szadek KM, Hoogland PV, Zuurmond de WW, Lange JJ, Perez RS. Nociceptive nerve fibers in the sacroiliac of the literature.ofNeurosurg J April2015; Spine. 23(1): 59-66. Zaidi HA, Montoure AJ, Dickman CA. Surgical and clinical efficacy of sacroiliac joint fusion: asystematic review 2012; 21(9): 1788-1796. Yoshihara H. Sacroiliac joint pain after lumbar/lumbosacral fusion: current knowledge. European Spine Journal Disorders and Techniques 2008; 21(8): 579-584. CL,Wise Dall BE. Minimally invasive sacroiliac arthrodesis: outcomes of anew technique. JournalSpinal of 6. Article Management: Six Whang PG, Cher D, Polly D, et al. Sacroiliac Joint Fusion Using Triangular Titanium Implants vs Non-Surgical Orthop Trauma Surg Arch. 1987; 106(4): 238- Waisbrod H, Krainick JU, Gerbershagen HU. Sacroiliac joint arthrodesis for chronic lower back pain. Arch B Place - Month Outcomes from aProspective Randomized Controlled Trial. Int J Spine Surg. 2015; 9: B oulevard, LopezSanchez F, -Sapena N, Rivera S luffton, -Pardo M, et al. Minimally Invasive Sacroiliac Joint Arthrodesis: C 29 240. -Paz M,-Lopez Verdu F. Minimally Invasive Sacroiliac Joint 910 •( - 800) 918 -368. 8924 www.eviCore.com Page V1.0.2018 50 of 57

Spine Surgery Regence Comprehensive Musculoskeletal Management Guidelines: Spine Surgery V1.0.2018

CMM-612: Grafts CMM-612.1: General Guidelines 52 CMM-612.2: Recombinant Human Bone Morphogenetic Protein rhBMP-2 (InFuse®) 52 CMM-612.3 Bone Marrow Aspirate Concentrate (BMAC) 53 CMM-612.4: Bone Graft Substitutes 54 CMM-612.5: Procedure (CPT®) Codes 54 CMM-612.6: References 55

Spine Surgery

© 2018 eviCore healthcare. All rights reserved. Page 51 of 57 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare  rhBMP C    CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery : Recombinant Human Bone Morphogenetic Prot Bone Human Morphogenetic MM-612.2: Recombinant   medically necessary Recombinanthuman bone morphogenetic protein rhBMP  MarrowAspirate Concentrate Definition/techniquebone for marrowaspirate concentrate( Requirements For prior authorization requirements, see case a The determination of medical necessity for grafts (orthobiologics) is always on made

612.1: General Guidelines-612.1:General             failure fusion of risk High TLIF]) [ALIF], posterolateral lumbar fusion, posterior lumbar interbody fusion [PLIF and Approved lumbar spine fusion (stand demineralized bone matrix (DBM) to fabricate composite hybrid grafts. hydroxyapatite (HA) substrates and other porous ceramics as well as particulate osteoconductive biocompatible substrates of choice e.g. collagen sponges, the red blood cell fractions and plasma. aspirate is then transferred to the concentrating device (centrifuge) that removes using asequential technique produces the lowest yield of viable cells. iliac crest to avoid dilution with peripheral blood. requires that no more than 2 mL of blood is aspirated from any given area in the of viable connective tissue osteoprogenitor cells. A bone marrow aspirate concentrate (BMAC) is intended as a high concentration trajectories until the desired amount is obtained. (Muschler) through a small incision made over the iliac crest through different of marrow from the iliac crest is performed using asequential technique

-2 (InFuse - scoliosis, occiptocervical pathology) Pediatric patients at very high risk of fusion failure (e.g., neuromuscular arthriti Autogenous bone graft is not available or of poor quality (e.g., rheumatoid Compromised graft bed (e.g., prior radiation therapy) Steroid use Osteoporosis Alcoholism Renal disease Diabetes Current Thoracolumbar Grade III or worse spondylolisthesis moreOne orprevious failedspinal fusion(s) by

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Spine Surgery Regence Comprehensive Musculoskeletal Management Guidelines: Spine Surgery V1.0.2018

 Autologous bone and bone marrow harvest are not feasible or are not expected to promote fusion  In combination with FDA-approved fusion device for a single-level anterior interbody lumbar or lumbo-sacral fusion (e.g., ALIF) surgery for no more than Grade III spondylolisthesis at the involved level  Recombinant human bone morphogenetic protein rhBMP-2 (InFuse) is considered experimental, investigational, or unproven for ALL of the following:  Skeletally immature patient  Planned use of grafting in the vicinity of a resected or extant tumor  Known contraindications (e.g., pregnancy, hypersensitivity/allergy, infection, spinal malignancy)  Treatment of the cervical or thoracic spine other than in pediatric patients at very high risk for fusion failure (e.g., neuromuscular scoliosis occiptocervical pathology)  Lumbar spine surgery via posterior approach

CMM-612.3: Bone Marrow Aspirate Concentrate (BMAC)  Bone marrow aspirate concentrate (BMAC) is considered medically necessary for hybrid or composite grafting (combined osteoinductive and osteoconductive) including autologous corticocancellous iliac crest bone graft (ICBG) for postero- lateral lumbar spinal fusion surgery (spondylodesis) with or without spinal instrumentation.  Bone marrow aspirate concentrate (BMAC) is considered experimental, investigational, or unproven for ALL of the following:  BMAC combined with allograft or synthetic scaffold as a substitute for autologous bone graft for spinal fusion surgery (spondylodesis) with or without spinal instrumentation  Application to cervical/thoracic spinal fusion surgery with or without instrumentation  Anterior spinal fusion surgery with or without instrumentation  Application to spinal decompression without fusion  Disc arthroplasty surgery  Use of lumbar interspinous devices  Obtaining BMAC without using the sequential technique as outlined  Use of unfractionated BMAC  Infection (e.g.,discitis, epidural abscess, osteomyelitis)  Primary or metastatic neoplastic disease of the spine

Spine Surgery

© 2018 eviCore healthcare. All rights reserved. Page 53 of 57 400 Buckwalter Place Boulevard, Bluffton, SC 29910 • (800) 918-8924 www.eviCore.com 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare CMM           considered ALL CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery r only This individual’s policy or benefit entitlement structure as well as claims processing rules. d Thislist maynot beall inclusive andnotis intendedtousedbe coding/billing for purposes. The final e etermination of reimbursement for services theis decision of the health plan and is based on the quir +20939 + + + + + OptiMesh Ceramic reco Bone graft substitutes used to reduce donor site morbidity (e.g., iliac crest donor site BacFast (e.g.,for fusion TruFuse Allograft bone graft substitutes used exclusively asstand enhance bone healing Platelet rich plasma (e.g., autologous platelet derived growth factor) when used to to enhance bone healing gro Human cell therapy)when used to enhance bone healing - Cell Human amniotic membrane bone graft substitute Device Revision Posterolateral INFUSE/MASTERGRAFT™ r CPT 20938 20937 20936 20931 20930 hBMP

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B Place ® ed from same incision (List separately separately (List spinous process, incision or laminar same fragments) obtain from ed Auto graft spine for surgery only (includes harvesting the graft); local (e.g., ribs, primary procedure) Allograft, structural, spine for surgery only (List separately addition in to code for only (List separately addition in to code primaryfor procedu Allograft, morselized, or placement osteopromotive of material, spine for surgery or fascial incision (List separately addition in to code primary for procedure). Bone marrow aspi code primaryfor procedure) or tricortical (through separate or skin fascial incision) (List separately addition in to Auto graft spine for surgery only (includes harvesting the graft); structural,bicortical procedure) separate skin or fascial incision) (List separately in addition to code for pri Auto graft spine for surgery only (includes harvesting the graft); morselized (through additionin to code primary for procedure) HDisolated for facet fusion)

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Spine Surgery 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 14. 13. Benglis D, MY,Wang Levi AD. A comprehensive review of the safety profile of bone morphogenetic protein in 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. CMM Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery 16. 15. 17. 19. 18. 27. 22. 21. 20. 26. 25. 24. 23. clinical studies.Spine . posterolateral lumbar spine fusion in humans: a prospective, randomized clinical pilot trial: 2002 Volvo Award in Boden SD, Kang SandhuJ, H, Heller JG. Use of recombinant human bone morphogenetic protein-2 to achieve polyetherethereketonespacerbone and morphogenetic protein.Neurosurg:J. Spine. 2005 May;2:521-5. Boakye M,Mummaneni PV, Garrett M, Rodts G, Haid R. Anterior cervical discectomy and fusion involving a spine surgery. Neurosurgery. 2008 May;62(5 Suppl 2):ONS423-31; discussion ONS431. ring and the ATLANTIS anterior cervical plate. Spine. fusion study using recombinant human bone morphogenetic protein CORNERSTONE the with -2 Baskin DS, Ryan P, Sonntag autogenous rib graft: a prospective controlled study. Spine (Phila Pa 1976). 2008 Nov 1;33(23):2570-5. Bapat MR, Chaudhary K, Garg H, Laheri V. Reconstruction of large iliac crest defects after graft harvest using fusion. Indian Orthop.J 2009 Jul; beta-tricalcium phosphate mixed with bone marrow aspirate a as bone graft substitute for posterolateral spinal Bansai S, Chauhan V, Sharma S, Maheshwari R, Juyal A, Raghuvanshi S. Evaluation of hydroxyapatite and Apatech, Inc. Acti American Academy of Orthopaedic Surgeons. Research. Statistics on Orthopedic Patients andConditions. 2006. American Academy of Orthopaedic Surgeons. Spinal fusion. Updated 2007 September. American Academy of Orthopaedic elderly patients. Eur Spine J. 2015 Nov; 24(11): 2567-72. marrow aspirate with allograft and demineralized bone matrix for posterolateral and interbody lumbar fusion in Ajiboye RM, Hamamot JT, Eckardt MA, JC. ClinicalWang and radiolgraphic outcomes of concentrated bone On Agency for Healthcare Research and Quality (AHRQ). Bone Morphogenetic Protein: The State of Evidence for stimulating devices and orthobiologics in healing nonunion fractures. Updated 2005 Sep 21. Agency for Healthcare Research and Quality (AHRQ). Technology assessment: the role of bone growth systematic review. Neurosurg J Spine. 2009 Dec;11(6):729- W CA, Welch Umscheid K, R, Williams Agarwal Jun;87-A(6):1205- allografts: clinical and radiographic outcomes in anterior lumbar spinal surgery. J Bone Joint Surg Am. 2005 Burkus JK, Sandhu HS, Gornet MF, Longley MC. Use of rhBMP 1;20:1 Bohner M. Design of ceramic humans. Int PeriodonticsJ Restorative Dent. 2005 Feb;25( bovine porous bone mineral, GTR, andplatelet Camargo PM, Lekovic V, Weinlaender M, Vasilic N, Madzarevic M, Kenney EB. A reentry study onthe use of fusion using rhBMP Carragee EJ, Mitsunaga KA, Hurwitz EL, Scuderi GJ. Retrograde ejaculation after anterior lumbar interbody trials in spinal surgery: emerging safety concerns and lessons learned. Spine 2011J. Jun;11(6):471-91. Carragee EJ, Hurwitz EL, Weiner BK. A critical review of recombinant human bone morphogenetic protein-2 resistant matrix versus iliac crest bone graft. Spine. 2006 Oct 15;31(22):2534-9. instrumented posterolateral fusions with recombinant human bone morphogenetic prot Dimar JR, Glassman SD, Burkus KJ, Carreon LY. Clinical outcomes and fusion success at 2 years of single-level Carlisle E, Fischgrund JS. Bone morphogenetic proteins for spinal fusion. Spine. 2005;5:240S exposed to bone morphogenetic protein for spine surgery. Spine. 2008 Feb 15;3 Carreon LY, Glassman SD, Brock DC, Dimar JR, Puno RM, Campbell MJ. Adverse events patientsin re- instr Carreon LY, Glassman SD, Anekstein Y, Puno RM. Platelet gel (AGF) fails to increase fusion rates in with instrumentation. A prospective randomized trial. Bone J Joint Surg Am. 2009 Jul;91(7):1604-13. protein-2 on an absorbable collagen sponge with an osteoconductive bulking agent in posterolateral arthrodesis Dawson E, Bae HW, Burkus JK, Stambough JL, Glassman SD. Recombinant human bone morphogenetic arthrodesis. BoneJ Joint Surg Am. 2009 Jun;91(6):1377-86. analysis of an optimized rhBMP Dimar JR 2nd, Glassman SD, Burkus JK, Pryor PW, Hardacker JW, Carreon LY. Clinical and radiographic feasibility. Spine (Phila Pa 1976). 2010 May 20;35(12):118 controlled, multicenter study of osteogenic protein-1 in instrumented posterolateral fusions: report on safety and Delawi D, Dhert RillardonWJ, L, Gay E, Prestamburgo D, Garcia-Fernandez C. A prospective, randomized, Apr;18(4):449- Chaua AMT,Mobbs RJ. Bone graft substitutes in anterior cervical discectomy and fusion. Eur Spine J. 2009 -Label and Off -612.6 umented posterolateral fusions. Spine. 2005 May 1;30(9):E243-6; discussion E247. - 12. B Place : References 64. Label Use.-Label August6, 2010. fuse. 12. -2: a cohort controlled study. Spine J. 2011 Jun;11(6):511-6. B oulevard, 2002;27(23):2662- - V, R,Westmark Widmayer MA. A prospective, randomized, controlled cervical based cements and putties for bone graft substitution. Eur Cell Mater. 2010 Jul -2 formulation as an autograft replacement in posterolateral lumbar spine

43(3): 234-9. S luffton,

Surgeons. Nonunions. Updated 2007 September. 73. C 29 -rich plasma thein regenerative treatment of intrabony defects in C. Osteoinductive bone graft substitutes for lumbar fusion: a 910 •( 2003;28(12):1219 - 800) 918 5- 1):49-59. 40. 91. 2 in combination-2 in with structural cortical 8924 -25. 3(4):391-3. ein

-2/compression www.eviCore.com -9S. -SR allograft Page V1.0.2018 55 of 57

Spine Surgery 42. 41. 40. 39. 38. 51. 50. 49. 48. 47. 46. 45. 44. 43. 37. 36. 35. 34. 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 52. 33. 32. 31. 30. 29. 28. Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery 53. 54. clinical studies.Spine . (BMP-7) andautograft bone in human noninstrumented posterolateral lumbar fusion: 2002 Volvo Award in Johnsson R, Stromqvist B, Aspenberg P. Randomized radiostereometric studycomparing osteogenic protein-1 20; 39(9): 695-700. Johnson RG. Bone marrow concentrate with allograft equivalent to autograft lumbarin fusions. Spine 2014 Apr 15;19(6):E13. Helm GA, Gazit Z. Future uses of mesenchymal stem cells in spine surgery. Neurosurg Focus. 2005 Dec Jun;11(6):507-10. osteolysis with bone morphogenetic protein use in transforaminal lumbar interbody fusion. Spine 2011J. Helgeson MD, Lehman RA Jr, Patzkowski JC, Dmitriev AE, Rosner MK,Mack AW. Adjacent vertebral body 24. concentrate for the healing of the instrumented posterolateral lumbar fusion. Spine J. 2014 Jul 1; 14(7): 1318- Hart R, Komzak M, Okai F, Nahlik D, Jajtner P, Puskeiler M. Allograft alone versus allograft with bone marrow fusion. Spine (Phila Pa 1976). 2008 Sep 15;33(20):2153- substitute for iliac crest bone graft in multilevel adult spinal deformity surgery: minimum two-yearevaluation of Mulconrey DS, Bridwell KH, Flynn Cronen J, GA, Rose PS. Bone morphogenetic protein (RhBMP Spine. 2007 May 1;32(10):1067-71. morphogenetic protein and basic fibroblast growth factor on cultured mesenchymal stem cells for spine fusion. Minamide A, Yoshida M, Kawakami M, Okada M, Enyo Y, Hashizume H, Boden SD. The effects of bone 2008 Jul;22(6):432 Mehta S, JT.Watson Platelet rich concentrate: basic science and current clinical applications. Orthop J Trauma. morphogenetic protein-2 (INFUSE((R)) Bone Graft). Int Orthop. 2007 Dec;31(6):729-734. McKay Peckham WF, SM, Badura JM. A comprehensive clinical review of recombinant human bone for adult spinal deformity. Spine (Phila Pa 1976). 2005 Sep 1;30(17 Suppl):S110-7. Luhmann SJ, Bridwell KH, Cheng I, Imamura T, Lenke LG, Schootman M. Use of bone morphogenetic protein-2 limitations, and future direction. Eur Spine 2006J. Aug;15 Suppl 3:S406- Leung VY, Chan D, Cheung KM. Regeneration of intervertebral disc by mesenchymal stem cells: potentials, arthrodesis. Khashan M, Inoue S, Berven SH. Cell based therapies as compared to autologous bone grafts for spinal surgery. Orthop Clin North Am Khan SN, Sandhu HS, Lane JM, FP Cammisa Jr, Girardi FP. Bone morphogenetic proteins: relevance in spine substitute: emphasis of surgicalexploration andhistologic assessment.Spine. 2006May1;31(10):1067 -74. posterolateral lumbar fusion using osteogenic protein (OP -1 Kanayama M, Hashimoto T, Shigenobu K, Yamane S, Bauer TW, Togawa D. A prospective randomized study of structure to clinical use. Braz J Med Biol Res. 2005 Oct;38(10):1463-7 Granjeiro JM, Oliveira RC, Bustos phosphate/collagen carrier in posterolateral spinal fusion. Spine. 2005;30(15):1694- human bone morphogenetic protein- Glassman SD, Dimar JR, Carreon LY, Campbell MJ, Puno RM, Johnson JR. Initial fusion rates with recombinant rhBMP-2 for posterolateral lumbar fusion in Glassman SD, Dimar JR 3rd, Burkus K, Hardacker JW, Pryor PW, Boden SD, Carreon LY. The efficacy of Aug;77(8):626-31. Gautschi OP, Frey SP, Zellweger R. Bone morphogenetic proteins in clinical applications. ANZ Surg. J 2007 systematic review. Spine. 2007 Apr 1;32(7):824- Mussano F, Ciccone G, Ceccarelli M, Baldi I, Bassi F. Bone morphogenetic proteins and bone defects: a review. Health Technol Assess. 2007 Aug;11(30):1- a systematic fusion: spinal and effectiveness fractures bone of morphogenetic of proteins thein non-healing Garrison KR, Donell S, Ryder J, rhOP morphogenetic protein-7) in the treatment of tibial nonunions: aprospective, randomized clinical trial comparing Friedlaender GE, Perry CR, Cole JD, Cook SD, Cierny G, Muschler GF, et al. Osteogenic protein-1 (bone fractures. February 16, 2005. Feldman MD. Recombinant human bone morphogenetic protein-2 for spinal surgerytreatmentand of opentibial EpsteinPros,NE. and cons,INFUSE costsof spinal in surgery Joint Surg Am Einhorn TA. Clinical applications of recombinant human BMPs: early experience and future development. BoneJ perspective on protein interaction with the nervous system. Spine 2011J. Jun;11(6):500-5. Dmitriev AE, Lehman RA Jr, Symes AJ. Bone morphogenetic protein-2 andspinal arthrodesis:thebasic science s Nandi SK, Roy S, Mukherjee P, Kundu B, De DK, Basu D. Orthopaedic applications of bone graft & graft 2014. NASS Coverage Policy Recommendations. Recombinant Human Bone Morphogenetic Protein (rhBMP ubstitutes: areview. Indian J Med Res. 2010 Jul;132:15- -1 with fresh bone autograft. J Bone Joint Surg Am

B Place Spine 2013 Oct 1; 38(21): 1885-91. . 2003;85-A(Suppl 3):82 -8. B oulevard, 2002;27(23):2654- . 2002;33(2):447-63.

Shemilt I, Mugford M, Harvey I, Song F. Clinical effectiveness and cost -Valenzuela JC, Sogayar MC, Taga R. Bone morphogenetic proteins: from S luffton, 2/compression resistant matrix anda hydroxyapatite and tricalcium -8. 61.

smokers.Spine. 1;32(15):1693 2007Jul -8. C 29 30. 910 •( 150, iii -iv. . 9. 2001;83-A(Suppl 1 Pt 2):S151 - - 800) 918 30. - 1) versus local autograft with ceramic bone . Surg Neurol Int. 2011 Jan 24;2:10. 8924 3. 13. Epub13. 2006Jul 15. 8.

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Spine Surgery 76. 75. 400 Buckwalter . Allrightseserved. © 2018eviCoreh ealthcare 60. 59. 58. 57. 56. 55. Regence ComprehensiveMusculoskeletalManagementGuidelines:SpineSurgery 74. 73. 72. 71. 70. 68. 67. 66. 65. 64. 63. 62. 61. 69. tissue engineering. Biomed J Mater Res B Appl Biomater. 2010 Apr;93(1):285- Yu NY, Schindeler A, Little DG, Ruys AJ. Biodegradable poly(alpha bone grafting. Spine 2012 Feb 1; 37(3): E174-9. phosphate and trephine bone for lumbar postero alteral fusion: aprospective, comparative study versus local Shinomiya K, Okawa A. Hybrid grafting using bone marrow aspirate combined with porous B Ya rhBMP-7 for spinal fusion. February 14, 2012. Disorders: A Systematic Review of the Clinical Orthpaedic Literature. BoneJ Joint Surg 2018; 100: 517- Variability in the Preparation, Reporting, and Use of Bone Marrow Aspirate Concentrate in Musculoskeletal Piuzzi NS, Hussain ZB, Chahla Cinque J, ME,Moatshe G, Mantripragada V, Muschler GF, LaPrade RF. Oct;99(19): 1673-82. Marrow Aspiration for Harvest of Connective Tissue Progenitors from the Human Iliac Crest. JBJS. 2017 Patterson TE, Boehm C, Nakamoto C, Rozic R, E, PiuzziWalker Muschler N, GF. The Efficiency of Bone 1;33(19):E680-92. morphogenetic proteins for posterolateral fusion of lumbar spine: ameta- Papakostidis C, Kontakis G, Bhandari M, Ontario Ministry of Health and Long-Term Care; March 2004. spinal surgery for degenerative disc disease. Health Technology Scientific Literature Review.Toronto, ON: Ontario Ministry of Health and Long-Term Care, Medical Advisory Secretariat. Bone morphogenetic proteins and Health andLong-Term Care; April 2005.. bone nonunion. Health Technology Assessment Scientific Literature Review. Toronto, ON: Ontario Ministry of Ontario Ministry of Health and Long-Term Care, Medical Advisory Secretariat. Osteogenic protein- biological and clinical assessment. Eur Spine J. 2012 Dec; 21(12): 2665- per Odri GA, Hami A, Pomero V, Seite M, Heymann D, Bertrand Washington State Health Care Authority. Health Technology Assessment. On- May 4 minimum crest autograft for arthrodesis: posterolateral lumbar Appannagari A, Patel M, Fischgrund JS. The safety and efficacy of OP Vaccaro AR, Whang PG, Patel T, Phillips FM, Anderson DG, Albert TJ, Hilibrand AS, Brower RS, Kurd MF, U.S. Food and Drug Administration. Osteofil Allograft Paste. 510(k) summary Summary of Safety andEffectiveness Data. January 10, 2022. U.S. Food and Drug Administration. InFUSE™ Bone Graft/LT Apr 27. U.S. Food and Drug Administration. New humanitarian device approval: OP 30. U.S. Food and Drug Administration. Supplement S002. July 2004. InFU fusion device-P000058. Updated 2002 Sep 6. U.S. Food and Drug Administration. New device approval: InFUSE™ bone graft/LT 2004. U.S. Food and Drug Administration. New device approval: INFUS U.S. Food and Drug Administration. INTER FIXThreaded Fusion Device: important medical information. usage of rhBMP Smucker JD, Rhee JM, Singh K, Yoon ST, Heller JG. Increased swelling complications associated with off 2006 Aug;19(6):416-23. posterolateral lumbar spine fusion: aprospective CT Singh K, Smucker JD, Boden SD. Use of recombinant human bone morphogenetic protein controlled clinical trial. Neurosurgery. 2005 Sep;57(3):526-9; discussion 526-9. Resnick DK. Reconstruction of anterior iliac crest after bone graft harvest decreases pain: a randomized, morphogenetic protein-2. Spine. 2006 May 1;31(10):E277-84. lessons from anterior lumbar interbody fusion using femoral ring allografts and recombinant human bone Pradhan BB, Bae HW, Patel U.S. Food and Drug Administration. New humanitarian device approval: OP tapered fusion device-P000058. mada T,mada Yoshii T, Sotome S, Uyasa M, Kato T, Arai Y, Kawabata S, Tomizawa S, Sakaki K, Hirai T, -operative procedure for concentrated bone marrow adjunction in postero- -Jun;8(3):457-65. B Place 2 in the-2 in anterior cervical spine. Spine. 2006 Nov 15;31(24):2813 -9. B oulevard,

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Giannoudis PV. Efficacy of autologous iliac crest bone graft and bone C 29 910 •( -scan analysis at one and two years. SpinalJ Disord Tech. - 800) 918 -Vasseur A, Skalli DelecrinW, DevelopmentJ. of a -CAGE™ Lumbar Tapered Fusion Device. -year follow E ® -hydroxy acid) polymer scaffolds for bone

8924 bone graft 1 (rhBMP-1 -7) as a replacement for iliac SE™ boneSE™ graft/LT analysis of the results. Spine. 2008 Sep 72. -up of a pilot study. Spine J. 2008 1 Putty-1 -1™ - -1™

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